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  • • Severe, diffuse abdominal pain

    • Gross or occult intestinal bleeding

    • Minimal physical findings

    • Radiographic findings of vascular occlusion

    • Operative findings of ischemic bowel

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Epidemiology

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  • • Predominantly a disease of the elderly

    • Tissue injury is caused by both ischemia itself as well as reperfusion

    Mesenteric arterial emboli (50%): Commonly originate from mural thrombus in an infarcted LV or clot in a fibrillating LA

    Thrombosis of a mesenteric artery (25%): The end result of atherosclerotic stenosis; often a history of intestinal angina

    • Rare causes of acute arterial occlusion include:

    • -Dissecting aortic aneurysm

      -Connective tissue disorders

      -Cocaine ingestion

    Thrombosis of mesenteric veins (5%): Associated with portal hypertension, abdominal sepsis, hypercoagulable states, or trauma

    • Nonocclusive mesenteric ischemia accounts for the remaining 20% of cases of mesenteric ischemia

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Symptoms and Signs

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  • • Severe, poorly localized abdominal pain that is often out of proportion to physical findings

    • Nausea and vomiting

    • Diarrhea

    • Shock

    • GI bleeding

    • Abdominal distention

    • Abdominal tenderness

    • Peritonitis

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Laboratory Findings

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  • • Leukocytosis

    • Serum amylase is elevated

    • Significant base deficits

    • Increased serum phosphate

    • Anemia

    • Increased serum lactate

    • Antithrombin III deficiency and other abnormalities of coagulation should be sought in cases of venous thrombosis

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Imaging Findings

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  • Abdominal x-ray:

    • -Nonspecific

      -Absence of intestinal gas

      -Diffuse distention with air-fluid levels

    Specific findings occur late

    • -Intramural gas

      -Gas in the portal venous system

    GI contrast radiography: Thumbprinting and disordered motility

    CT scan

    • -Diffuse distention with air-fluid levels

      -Intestinal wall thickening

      -Intramural gas

      -Gas in the portal venous system

    Mesenteric arteriography: The gold standard showing disrupted intestinal arterial blood flow or absence of a venous phase

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  • • Survival depends on diagnosis and operative treatment within 12 hours after onset of symptoms

    • In the early stages, there is a striking paucity of abdominal findings

    • Pain out of proportion to the objective findings is a hallmark of mesenteric vascular occlusion

    • Later in the disease course, abdominal distention and tenderness occur

    • Shock and generalized peritonitis eventually develop

    • Causes of hypercoagulability should be sought postoperatively in cases of venous thrombosis

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Rule Out

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  • • Acute pancreatitis

    • Strangulation obstruction

    • Nonocclusive intestinal ischemia

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  • • CBC

    • Serum electrolytes

    • Serum amylase

    • Serum lactate

    • ABG measurements

    • Abdominal x-ray

    • CT scan

    • Arteriography

    • Hypercoagulable studies (venous thrombosis)

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When to Admit

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  • • All cases

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Surgery

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  • • Resection of all involved gut; revascularization of proximal stenosis indicated to salvage viable bowel; thrombectomy usually unsuccessful

    • Role of angioplasty and stenting combined with operation depends upon the precise vascular lesions

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Indications

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  • • Acute arterial embolism or thrombosis

    • Acute ...

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